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More than 800 serious incidents reported in Norfolk’s NHS in just one year

PUBLISHED: 08:34 25 February 2018 | UPDATED: 14:32 25 February 2018

File photoof a hospital ward. Picture Peter Byrne/PA Wire.

File photoof a hospital ward. Picture Peter Byrne/PA Wire.

The number of serious incidents (SIs) reported in Norfolk’s NHS has been revealed in a new report.

The most incidents were recorded at Norfolk Community Health and Care (NCHC) which covers the whole county, followed by the region’s mental health trust.

NCHC recorded 276 SIs in 2016/17 - the seventh highest in the country out of 171 respondents - but this was down from 550 the year before.

And the region’s ambulance trust recorded the most SIs out of the country’s ambulance trust with 95 - up from 83 the year before.

NCHC pointed to the larger population it served as a reason for the higher numbers, as well as the majority of their patients being elderly or home-based.

And EEAST added they were more stringent with what they counted as a SI than elsewhere.

An EEAST spokesman said the trust reported “near miss SIs [...] which can be an incident that had the potential to cause harm but didn’t” to develop a learning culture. And added: “With this in mind, of the 95 serious incidents reported in 2016/2017, just 44pc would previously have been reported as a SI, which is a decrease when compared to the same statistics in the previous financial year where 71pc of incidents reported would have been considered a SI.”

In the research, from medical negligence solicitors Blackwater Law, it was recognised different trusts would define SIs in different ways. The report said there was no standard definition but the NHS sets out some guidelines that they are considered to be adverse events where the consequences to patients and NHS organisations are so significant that a heightened level of response and investigation is justified.

Events that constitute a SI include unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm, as well as incidents affecting an NHS trust’s ability to provide services.

At Norfolk’s acute hospitals the Norfolk and Norwich University (NNUH) reported 115 SIs in 2016/17 (down from 154 the previous year).

At the Queen Elizabeth Hospital (QEH) in King’s Lynn there were 46 SIs, down from 49.

And the James Paget University Hospital (JPUH) in Gorleston had the lowest number of SI out of the county’s whole NHS, reporting 37 in 2016/17 - down from 46 in 2015/16.

Mental health

At the region’s mental health trust, Norfolk and Suffolk Foundation Trust (NSFT) there were 242 SIs in 2016/17 - down from 261 the previous year.

This was the fourth highest rate out of the country’s 53 mental health trusts.

Nationally, the most common type of SI in mental health was an unexplained death, followed by self-harm and suicide (attempted and actual, including threats).

Dawn Collins, NSFT director of nursing, quality and patient safety, said: “NSFT is one of the largest mental health trusts in the UK covering 3,500 square miles across Norfolk and Suffolk, including Great Yarmouth and Waveney – equivalent to 7pc of the country’s landmass.

“Unlike some mental health trusts, we provide secure services for people who have an acute mental health need who have also come into contact with the criminal justice system. In addition, we offer services in Norfolk for people with drug and alcohol addictions who often die from accidental overdose, or physical conditions linked to their addictions, such as lung and heart disease.

“Our trust is a high reporter of unexpected deaths and serious incidents, but we are also a trust which demonstrates low levels of harm to our patients.

“Being a high reporter is regarded as a positive approach in the NHS, and reporting is what keeps services and patients safe.

“We have introduced enhanced training for staff investigating incidents, and we have employed additional investigation improvement managers to better support effective and consistent investigation and learnings in our services.

“As a result of investigations, where there is a need for improvement or a lesson to be learned we take efficient action, and we ensure that learning is shared throughout our whole organisation.”

‘We expect high numbers’

Anna Morgan, director of nursing at NCHC, said she would expect the number of SI to be higher due to looking after more elderly and home-based patients.

She said: “We naturally encounter pressure ulcers and falls in the course of our work.”

Most of NCHCs SIs were due to pressure ulcers, but Ms Morgan added: “Simply because pressure ulcers are in our care doesn’t mean that they are preventable or that they developed during our care – for example, pressure ulcers in our care might include us going to a visit for the first time and finding the patient has an ulcer. We would report it.

“Reporting SIs is an essential part of delivering improved services - we have good processes and a high reporting culture where our staff feel supported in reporting and our focus is on patient welfare and continuous improvement.

“Our priority is patient care, so all incidents are taken seriously and a root cause analysis investigation is undertaken so that we can learn from the incident and improve practice.”

Anna Hills, director of governance at JPUH, said: “As a learning organisation, we will investigate and strengthen procedures where any issues are identified as part of our ongoing commitment to safe patient care.“

A spokesman for the NNUH said: “As a trust, the significant improvements in quality and safety that have been achieved are due to improved working practice and better policies and procedure. We will continue to encourage our staff to report incidents to understand what happened, how it happened and why it happened to identify learning.”

The QEH did not respond to a request for comment.

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